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Preop Chemo Recommended for Locally Advanced Disease

Preop Chemo Recommended for Locally Advanced Disease

May 01, 1999

ORLANDOThe most important aspects in treating locally advanced
breast cancer are thorough preoperative chemotherapy and a treatment
team that combines chemotherapy, surgery, and radiation, two experts
said at a special session of the Society of Surgical Oncologys
Annual Cancer Symposium. The presenters were Frederick C. Ames, MD,
of the University of Texas M.D. Anderson Cancer Center, and A.
Marilyn Leitch, MD, of the University of Texas Southwestern Medical
Center, Dallas.

About 10% to 15% of the 200,000 new breast cancers diagnosed each
year are thought to be locally advanced, which includes tumors that
are large and/or have extensive regional lymph node involvement but
do not have distant metastatic spread on initial presentation.

The main advantages of preoperative chemotherapy are that it reduces
tumor burden prior to surgery and provides immediate treatment of
potential systemic disease, he said. Several cycles of a
doxorubicin-based regimen such as fluorouracil/doxorubicin/cyclophosphamide
(FAC) are typically followed by surgery and/or radiotherapy, then by
more chemotherapy.

Combined modality treatment is advised even for patients with
apparently very limited disease at presentation or with ulcerated
lesions at presentation. Dr. Leitch said that all locally advanced
breast cancer patients should be seen upfront by a medical
oncologist, a radiation oncologist, and a surgical oncologist, so
everybody is on the same page about how they are going to handle the patient.

The question of how many cycles of preoperative chemotherapy to give
came in for considerable discussion. Dr. Ames advised using at least
three cycles of preoperative chemotherapy before declaring a failure,
but not more than four.

He also urged clinicians to use radiographically detectable markers
and ultrasound or mammographic localization to document results in
patients who are in apparent complete remission (CR) after induction
and to document lymph node status histologically. Half of the
patients you think have a clinical CR do not, he warned.

Dr. Ames said that patients who have 50% or greater tumor reduction
in response to induction chemotherapy and who have negative axillary
nodes on ultrasound and on clinical examination are likely to have
only microscopic disease in the axilla, but patients who do not have
at least a 50% response to induction chemotherapy are poorer risks.

Sentinel lymph node examination is being tested as a method for
monitoring response to induction chemotherapy and may show promise
coupled with a less-than-standard axillary dissection. However, Dr.
Ames said that there have been problems in identifying adequate
sentinel nodes after induction chemotherapy. He suspects that larger
areas of disease may reduce the probability that adequate sentinel
nodes can be mapped, perhaps because of poor dye diffusion.

Preoperative chemotherapy is particularly important in patients with
ulcerated lesions, which can be very intimidating, Dr.
Leitch said. She has found that even extremely large and complex
ulcerated locally advanced breast cancers often become operable after
a course of preoperative chemotherapy.

Dr. Leitchs approach in such cases is to begin by debriding
dead tissue, but not doing aggressive debridement, which can
get you into trouble, she said. She then applies povidone
iodine solution and a nonadherent dressing and gives metronidazole by
mouth.

The patient is then given one or more cycles of a standard
preoperative chemotherapy regimen. Dr. Leitch has found that many
patients with ulcerated locally advanced breast cancer will improve
and become operable after chemotherapy.

Both surgeons reported increased interest among patients with locally
advanced disease in the possibility of breast conservation surgery or
immediate reconstruction after mastectomy.

Dr. Ames recommended that breast conservation be offered only to
patients who, after induction chemotherapy, have complete resolution
of skin edema, residual tumor smaller than 5 cm (and preferably
smaller than 3 cm), no extensive intramammary lymphatic invasion, no
extensive microcalcification, and no multicentricity. Any type of
residual skin edema is seen as a particularly bad prognostic sign.

Dr. Ames said that immediate reconstruction should be undertaken only
after consulting with the radiation oncologist to assure that
reconstruction will not interfere with postoperative radiation
therapy. Radiation and reconstruction sometimes dont
coexist very well, he said.

Dr. Leitch added that patients with other medical conditions such as
diabetes and obesity can have increased complications with
reconstructive surgery that can delay the overall treatment plan for
postoperative chemotherapy/radiation.

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